21742 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'ad identification I
l�I O� �p. pF]LwTNO.
Building Addrea,: V an 2
1742
rs same: Phone: A A
• c C CITY OF CUPERTINO-BUILDING DIVISION 1
trader"
same: • � gni �I APPLICATION I PERMIT
rp�' Coup " BUILDING-ELECTMCALPLUMBING-MECHANICAL CATEGORY CONTROL N
M/
C nglneer. r Lb' Oct e, QTY ELECTRIC PERMIT FEE BUILDII'.'G PERMIT INFO
tra
Address: PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby.fflrm that l am beensed under proeb!....f Chapter9(on..c APP11ANCESRESIDENrIAL JOB DESCRIPTION
Ingwith Sedi.n7000)of Divi,1.3ofthe Bushes dPr ffession.Cadmandmy
license Isla full( and c.0 (_l•'J (a'� PANdS
License Class_ LIff N
Date Contractor UP TO 2DUAMPS t0L
ARCHITECTS DECLARATION 701-l"A•MPS
its
Cp I understand my plans sh.11 be usee a public acmes. OVER 1000 AMPS SQ.FT.FLOOR AREAS/SQ.Ff.
itl Licensed Profealavl SIGNSELECTRICAL �y��5`.
S u� OWNERex rcpt fro DECLARATION
fn• E7 SPECIAL CIRCUIT/MISC
�..,�_ Ihembyafflrmthatlameaemptfmmthe Cantractor'e License law for the /
op ��
<9 p followingSB
reason.Section 7071.5, ues
sln .and Professions Code:Any dtyerr l N l rj '( 1
OLt- =ntywhichrequr apermlttocovtmu Ater,Impmvgdem lWh,ormpair ThMP'MEI'f7t OR TOLE INS!. 1(f.i
s�mg� anystmMmprlortoiU stance,alsorequlre,theappllcantfarsuchpermitto POWER DEVICES
C file a signed statement that he la licensed pursuant tothe provisions of the
pOu, Contndor'e License Law(Chapter 9(comurencleg with Section 7000)of LEA- VALUATION
b13pQ SWIMMING POOL FlECI'RIC
t„ sm basis fo the alleged ProfessionsC Any
violation f section herefrom and
the bash for the alleged exemption. Any t tola cavi of Section 7031.5 by any
uy6i
applicant fora permit aubjedsthe applicanttoa civil pevltyornd merethan O F
e. five hundred dollars(SS00. 1 (tel
I as owner of the WR so STORIES TYPECONSTRLCTION'
j�+ ❑ , Property,or he employees with wage as their sole
In&c.compenstion,Businessl do workandthestmrnrmh not orofferedLaw
C o sale(Sec 7Wly to Busan i
ness andfproperty Code:The Contnctofs LicenselawI is
S$ whodotapply torkht n rorpmpenywho nempibuilds yms,p e,thertam and OCC.GROUP RIS.UNITS
whodonsuchwork hlmvel(orthrough hisownemplgas,provided that such
Improvements am not Intended oronered forsale.If,however,thebullding or 0A'M -
i pmvementbsold wlthinovyearorammpietlomthe owner-bu0derwlll have
thAvden or proving that he did not baud orlmpmve fmpurposeofale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed ppRI55UANCE
contractus to construct the project(Sec.7041,Business and Ptdeaions Code:
The Contractors License Law does nor apply to an owner of property,who ALTER-DRAIN k VENT-WATER O+NN
Wilds or Improves thereon,and who contracts for such projects with a FEE SUMMARY
or,,➢.I.[duW licensed pursuant to the Cwtrador's License Law. BACX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for this reason
Owner Data
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
RECEIPT 0
WORKMAN COMPENSATION DECLARATION PEXTURF_S PER SCHOOL TAX Y_ N_
❑I hereby orf m that I have o«nitrons of consent m opythe a,(Sa RECEPr N
38m,LbofWorkers'Compewttonlvuranaoracenlfled copytM1ereo((Sec. GAS FA.SYSITM-]INCAOUTLEPS PARK FEE Y N
PolPoli Lb C.) RECEIPT
Cam env t )` ..�1Sa PA-•P•v GAS E.A.SYSTEM-OVER 4(EA) BUILDG DIVISI ON FE ES
[]CenlRed copy is hembyth the city CREASE/INDUSIRL WASTE BJTFRCEPTOR PLANCHECK FEE
Qcenlned ropy v mea with the dry inspection awl,lon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWEWSANETARY-S'rORM E.A.7WFT. Date Recei t# SSo
ITbh sector ion need nbe camplcted tithe permit V/orone hundred dollen
(6100)oWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
fannyifythat In the performance, work orkfor which this permit bOwed.
I shill not employ any person In any manner w as to become subject to the WATER SYSITM/TREATING
Workers Compensation taws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PEN 3. SD.FT. _ Da[e ReCel [#
Z O NOTICE TO MPLICANT:If,after making this Certificate of Exemption,you
N should become subjectto the Workers'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provisions orthls permit shall he
W > deemed revokes. BUILDING •E
S CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aformthat them V a constmctlon lending agency for the perform ELECTRIC F•EE
7 Z arta ofthc work!or which this permit ta.e,ed(Sec.309'/,Civ.C.) TOTAL:
00 lender.Narrc (� PLUMBING FEE
LL F Iender.Aadmss_ I" , 'I QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LEE
I cenlfythatl have read this app catic and statethat theabove informatlon
Ia. Lscomect.Iagrecto comply with allcity and county ordinanasand nate laws PERMIT ISSUANCE FEE PAI
} relating to building construction,and hereby authodmrepresentatives ofthis aYSl
[— cry to enter upon the abovcmentioned proerty pfar inspection purposes. ALTER OR ADD TO MSCIL
Z
V _ (We)agree to ave,Iodemnlly an d keep Extol.the City of C.penis. Date Reccipt#
against liabilities,judgments,costs a lid expenses which may In any y..c AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agalnstald Ci Incovtt7uenaoft egrarel ofthls permit.
/ G 7l // AIR HANDLING UNIT(OVER MEDIC IM- ) CONSTRUCTIONTAX
Slgvtumaf AE, nt/Contractor Date EXHAUST HOOD(W/DUCT) CO ST UCTIONTAXPAID:
HAlARDOUS MATERIALS ISCLOSURE IL( ( rilac/
Will the appllunt m rutum building occupant store or hand le haeardous HE (1
ATING UNIT0100000 BTI!) -=—L-a�—
material asdcfi nN by the Cupenl no Municipal Cade, or
9.17,and the _ Date Reeef t#
HealtharWSrfcty Codeta.-S�eNon75537(i)7 HEATING UNIT(OVER 100,M RTU) TOTAL: r
❑ Yes 1I No
Will the applicant or future building occupant use equipment orcievices VFNIILATIONFAN(SINGLERESIU) ISSUANCE DATE
which emit hanrd...air contaminants.,defined by the Bay Am.Alr ®
Quality Management District? BOILER-COMP(3FR'OR 100,000 BTLJ)
Yes
rNo
have read the b.auu mutedals rtginvivents under Chapter 6.95 of BOILER-COMP(OVER 1M,000 BTU)
the Califemla l lc.lth&Safety Code,Sections 25505,25573 and 7553/.I FEB 141991
undenTI
m nd that if the building docs not currently have.tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
mspomsihility to net lfy the ocavpant of the requirements which must be met-
-
PriortolssuanccoraCertiflcatoof cvpancy. C& rA or?"-
Owner or authoVd agent Date ISSUED BY:_I`
TOTAL: V
OFFICE COPY